If your son has been given a diagnosis of hypospadias, you were probably told that "the opening where urine comes out is not in the right place." That is not wrong, but it does not explain why an operation is needed, or why it may not be finished in one go.
This page sets out what hypospadias surgery is actually trying to correct. Knowing that also makes it clear what to ask in the consulting room.
What follows is limited to what the operation sets out to achieve. Depending on your son's situation, hormonal or chromosomal testing may be needed, and matters such as fertility in adulthood sit outside what surgery addresses. In particular, where hypospadias occurs together with testes that cannot be felt, separate investigation is recommended soon after birth. These are things to discuss separately with the treating doctor.
Hypospadias involves three problems at once
In hypospadias the opening for urine is not at the tip of the glans but somewhere along the underside of the penis. But a case where only the position of the opening differs is actually uncommon. Three features usually appear together.
First, the position of the opening. It may lie close to the glans, along the shaft, at the junction with the scrotum, or as far back as the perineum.
Second, a downward bend in the penis. The medical term is curvature. It may not be obvious to look at.
Third, an uneven distribution of skin. There is too little on the underside and a surplus on top, sitting like a hood.
They are not three unrelated problems that happen to coincide. They are three marks left by a single process — the formation of the penis during pregnancy stopping partway. That is why an operation correcting only one of them does not really make sense. Moving the opening and leaving the rest leaves the problem behind.
Surgery has three aims, likewise
There are a great many operations, but the conditions a good result must meet are the same.
- A natural stream from the tip of the glans
- No bend in the penis when erect
- An appearance he is satisfied with — and the person judging that is not the doctor but your son himself
Regarding the first, problems can arise: a fistula (urine leaking through a small opening), stenosis (the opening narrowing), a diverticulum (the urethra ballooning), spraying. These are a nuisance when they occur, but what to do about them is clear. Close it, open it, reduce it, reshape it. A further operation may be needed, but there is a way through.
The one that matters most is the bend
The three do not carry equal weight. What persists into adulthood when the first operation did not deal with it properly is the bend.
A bent penis looks shorter, is harder to expose, and leads to the skin being set too short to match. In other words, the bend is deeply bound up with how satisfactory the appearance turns out to be.
A child's penis is small, which makes the angle hard to judge. Once the nappy years are past, parents and doctors alike stop thinking about it. It does not announce itself by wet underwear as a fistula does, or during voiding as a stenosis does. It is invisible unless it is looked for.
So the problem only surfaces after puberty — more than ten years after the first operation. In a study of boys referred elsewhere because problems persisted after surgery, the commonest finding was residual curvature, and nearly 40% of their parents did not know their son had any bend at all.
Which is why the first operation's judgement matters
That the bend declares itself a decade later means two things.
One is that the assessment before surgery has to be accurate. Where the opening lies does not tell you how severe the case is. The degree of bending can only be established by checking directly during the operation. This is set out separately in Is my son's hypospadias a severe case?
The other is the choice of how to correct it. There are several ways to straighten a penis, and the more reliable ones mean a larger operation, sometimes done in stages. The simpler approach looks easier at the time, but reports suggest it is the one more likely to bend again with the years.
"Is my son's penis bent? How much?"
"How will that bend be corrected in this operation?"
"Will it be done in one operation or two? If two, why?"
"What is the chance of it bending again later?"
These matter partly for the answers, but also because they put the bend on the table. If the explanation stays with the opening and the risk of a fistula, the problem that lasts longest simply goes unmentioned.
Worth knowing in advance
Surgery does not make the penis larger. Dissatisfaction with size is something men raise not infrequently in adulthood, but this operation uncovers what was hidden and straightens what was bent; it does not enlarge the penis itself.
It may not be finished in one operation. Where the bend is pronounced or the opening lies well back, the repair is sometimes divided into two. Two operations is often the plan from the outset, not a sign that something failed.
Do not have him circumcised first. Circumcising a penis with hypospadias removes the skin that will be needed for the corrective operation. The European paediatric urology guideline recommends strongly against simple circumcision in this situation.
Frequently asked questions
When is surgery done?
Usually between six and eighteen months of age. It can vary with the child's situation — particularly the degree of bending and the size of the penis — so the timing is decided in discussion with the treating doctor. Anaesthesia, the catheter and dressings, and care after surgery are covered in Before and after hypospadias surgery.
He doesn't look especially bent to me.
It often does not show in the ordinary state. Curvature is judged on erection, and during the operation an erection is produced artificially so that it can be checked.
Which is better — doing it in two stages or in one?
There is as yet no clear conclusion that either is superior. What is more appropriate depends on the child — the degree of bending in particular, and the state of the tissue available to build the urethra — and on which approach the operating surgeon is practised in. It is worth knowing that two operations is usually the plan from the outset rather than a sign that something failed.
Will it affect his sex life later?
If the bend has been properly corrected, most men have no difficulty. If a bend remains, discomfort in adulthood is possible. That is why dealing with the bend at the first operation matters.
Does it need checking again in adulthood?
A bend can become apparent through puberty, so it is worth having it checked once around that time. It also helps to bear in mind that your son may find it difficult to raise the subject himself.
A series for clinicians covers this subject with the evidence behind it.
Part 1 — What are we aiming at?
Part 2 — What counts as a good result?
Part 3 — Matching severity
Written for clinicians.
References
- EAU Guidelines on Paediatric Urology. Hypospadias. European Association of Urology, 2026.
- Snodgrass W, Bush NC. Persistent or recurrent ventral curvature after failed proximal hypospadias repair. J Pediatr Urol. 2019;15(4):344.e1-344.e6.
- Rynja SP, de Jong TPVM, Bosch JLHR, de Kort LMO. Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood. J Pediatr Urol. 2011;7(5):504-515.